Year in review: health protection in NSW, 2012

Health protection involves the prevention and control of threats to health from communicable diseases and the environment. In New South Wales (NSW) in 2012 these functions were carried out by a range of groups, among them Health Protection NSW’s Communicable Diseases and Environmental Health Branches, the NSW Ministry of Health’s Population and Public Health Division, Public Health Units, clinicians, Local Health District services, local government, other government agencies, and communities.

In this report we highlight the major health outcomes and achievements related to Health Protection NSW’s activities in 2012, including some examples of health protection projects done in the field (Boxes 1–6). The health outcomes described in this report are measured mainly through routine surveillance data that are derived from notifications of selected diseases provided by doctors, hospitals and laboratories to Public Health Units under the NSW Public Health Act 2010.

Tables 1–6 show disease-specific data on notifiable conditions reported by: year of onset of illness; month of onset of illness; Local Health District; and age group and sex. Note that the degree to which notification data reflect the true incidence of disease varies and is subject to a range of caveats.¹

Table 1.  Disease notifications by year of onset of illness, NSW, 2003–2012

Table 2.  Incidence rate of disease notifications by year of onset of illness (per 100 000 population), NSW, 2003–2012

Table 3.  Disease notifications by month of onset of illness, NSW, 2012

Table 4.  Disease notifications by Local Health District of residence, NSW, 2012 (based on onset of illness)

Table 5.  Incidence rate of disease notifications by Local Health District of residence (per 100 000 population), NSW, 2012 (based on onset of illness)

Table 6.  Disease notifications by age group and sex of the case, NSW, 2012 (based on onset of illness)

In 2012 there were:

• no haemophilus influenzae type b notifications in children aged less than 5 years for the first time since 1993

• 5824 pertussis notifications (including one death in a 7-week old infant), a marked decrease from the record numbers in 2011 (>13 000)

• 172 measles notifications, of which two were imported from overseas, 169 were found to be linked to an imported case (measles virus D8), while another was locally acquired but presumably acquired from an imported case not identified through surveillance (measles virus B3). Most cases were notified by South Western Sydney and Western Sydney Local Health Districts. People of Pacific Islander ethnicity and Aboriginal people were disproportionately affected. There were 58 notifications in children aged less than 5 years, with 37 notifications in infants aged less than 1 year (too young to be vaccinated)

• 66 meningococcal disease notifications, the lowest number since the introduction of the meningococcal C vaccine in 2003. Of these, 43 were due to serogroup B (65%), five were due to serogroup Y (8%), four were due to serogroup W135 (6%), two were due to serogroup C (3%), and 12 were of an unknown serogroup (18%). The two cases of meningococcal C disease were reported in young adults who were not vaccinated. Meningococcal notifications have been declining for more than a decade

• 105 mumps notifications, an increase from the 67 reported in 2011. The highest notifications were in metropolitan areas and in under-vaccinated persons aged 30–34 years (n = 27), followed by those aged 35–39 years (n = 15)

• 566 invasive pneumococcal disease notifications, a slight increase compared with 529 in 2011. Serotype 19A was identified as the cause of infection in 33% of cases in children aged less than 5 years and 17% of the remainder of the cases where typing was available.

In 2012 there were:

• 2328 total hepatitis B case notifications, an 8% decrease compared with 2011 (n = 2525) and the lowest recorded number in 20 years (total notifications are mainly of people whose time of infection is unknown). Fifty-four percent of cases were male and 30% were aged between 25 and 34 years

• 28 newly-acquired hepatitis B case notifications, a 7% decrease compared with 2011 (n = 30). Eighty-six percent of cases were male

• 3292 total hepatitis C case notifications, similar to the number reported in 2011 (n = 3326). Sixty-four percent of cases were male and 34% were aged between 30 and 39 years

• 47 newly-acquired hepatitis C case notifications, an 8% decrease compared with 2011 (n = 51). Sixty-six percent of cases were male

• 409 cases of newly-diagnosed HIV infection, a 24% increase compared with 2011 (n = 330). The increase was across most at-risk groups. Most new HIV infections were reported to be male homosexually-acquired (81%), with other risk exposure categories reported as heterosexual contact (14%) and injecting drug use (2%). The proportion of people with newly-diagnosed homosexually-acquired HIV infection who reported having an HIV test in the year prior to diagnosis decreased slightly from 42% in 2011 to 40% in 2012, while the proportion of those who reported no previous HIV test prior to diagnosis rose from 14% in 2011 to 17% in 2012.

In 2012 there were:

• 21 291 chlamydia case notifications, a 4% increase compared with 2011 (n = 20 570). Fifty-six percent of cases were female and 58% were aged between 15 and 24 years

• 4127 gonorrhoea case notifications, a 43% increase compared with 2011 (n = 2882). Eighty-one percent of cases were male and 39% were aged between 20 and 29 years

• 498 infectious syphilis case notifications, a 19% increase compared with 2011 (n = 418). Almost all cases (96%) were male and 30% were aged between 40 and 49 years

• 29 lymphogranuloma venereum (LGV) case notifications, a 19% decrease from the 36 in 2011. All cases were male, and 35% were aged between 30 and 39 years. The number of LGV notifications has decreased since 2010 following an outbreak early in that year. The outbreak in NSW occurred in the global context of increased European rates of LGV infection in men who have sex with men.²

In 2012 there were:

• 7669 enteric disease case notifications, a 6% increase compared with the average annual count for the previous 5 years

• 2955 salmonellosis case notifications, a 15% decrease compared with 2011 and similar to the average annual count for the previous 5 years

• 61 outbreaks of probable foodborne disease affecting 662 people, an increase compared with 47 outbreaks affecting 797 people in 2011

• 803 outbreaks of probable viral gastroenteritis in institutions affecting 13 842 people, an increase compared with 525 notifications affecting 9071 people in 2011. The increase was likely related to the emergence of a new variant of norovirus GII.4 (known as Sydney 2012)³

• 13 point-source outbreaks of Salmonella Typhimurium infection affecting 162 people, most likely associated with the consumption of sauces and desserts prepared with raw eggs.

In 2012 there were:

• 61 Legionnaires’ disease case notifications due to Legionella pneumophila infection, compared with 60 cases in 2011. Public health investigations did not identify any common sources for these cases. L. pneumophila cases peaked in February 2012 with 12 cases reported. Notifications due to L. longbeacheae infection decreased (29 compared with 38 cases in 2011)

• 7999 notifications of influenza, an increase compared with 5773 notifications in 2011. Approximately 78% of laboratory-confirmed influenza was influenza A, with the influenza A(H3N2) strain predominating (97%). The incidence of influenza B increased later in the season and accounted for 21% of laboratory-confirmed influenza cases overall. While laboratory-confirmed influenza notifications are likely to represent only a small proportion of cases in the community, other indicators of increased influenza activity in 2012 were: an increase from June to September of people presenting to emergency departments with influenza-like illness (well above the normal expected range); and a marked increase in the number of reported outbreaks of respiratory illness in aged-care and other residential care facilities. The increase in morbidity due to influenza is most likely because the predominant strain (influenza A(H3N2)/Victoria/361/2011) was different to the strain in the 2012 influenza vaccine

• 471 notifications of tuberculosis, a decrease from the 523 cases reported in 2011

• three cases of multi-drug resistant tuberculosis (MDR-TB). Five cases per year were reported in 2010 and 2011.

In 2012 there were:

• 603 Ross River virus infection notifications, an increase from 579 in 2011

• 347 Barmah Forest virus infection notifications, a 24% decrease compared with the 458 notifications in 2011

• 208 dengue fever case notifications, a 50% increase compared with the 139 notifications in 2011. The majority of the cases in 2012 were linked to international travel; Indonesia was the most commonly reported exposure site (40%), followed by Thailand (21%), India (7%) and the Philippines (5%). While there currently is no local transmission of dengue fever in NSW, it is the most common mosquitoborne viral disease of humans worldwide and represents a major international public health concern

• 70 malaria case notifications, compared with 77 in 2011. All were acquired overseas. Travel to India was the most commonly reported exposure site (19%), followed by Sudan and Pakistan (both 10%)

• no confirmed cases of flavivirus infections, Kunjin virus infections or Murray Valley encephalitis virus infections notified

• two confirmed cases of Chikungunya, both acquired outside Australia (India and Kenya); this is a decrease from the 10 cases notified in 2011.

In 2012 there was:

• a slight decrease in Q fever case notifications (116 compared with 137 in 2011). Q fever was the most commonly notified zoonotic disease in 2012

• a slight decrease in brucellosis infections (four compared with six in 2011). Two cases were overseas-acquired and two infections were in hunters of feral pigs in Northern NSW.

In 2012 NSW Health:

• maintained high immunisation coverage rates for children at 1, 2 and 5 years of age (Table 7). While coverage rates for Aboriginal and non-Aboriginal children are comparable at 2 and 5 years of age, coverage for Aboriginal children is less at 1 year of age and Aboriginal children are more likely to be vaccinated late at any age

• funded a pilot program to employ Aboriginal Health Workers to work collaboratively with existing services to promote timely vaccination of Aboriginal children through targeted interventions

• developed an immunisation awareness campaign to inform the community and providers about the importance of ensuring that children are fully vaccinated on time

• successfully implemented the transition from Prevenar 7 to Prevenar 13 vaccine for children at 2, 4 and 6 months of age, and a supplementary program for children who had commenced Prevenar 7 vaccination to provide greater protection against pneumococcal disease

• introduced a more focused pertussis control strategy by offering new mothers free pertussis vaccine in the maternity unit after the birth of their child or via their general practitioner (GP) within 2 weeks post-birth

• increased immunisation coverage rates for adolescents in the NSW School-Based Vaccination Program for vaccines offered to students in Years 7 and 10 (Table 8)

• facilitated the provision of free seasonal influenza vaccine to people at high risk of severe influenza complications. The NSW Health Population Health Survey estimated that 31% of all respondents (95% CI: 28–33%) interviewed during August and September 2012 had received a seasonal influenza vaccine in the previous 12 months; vaccine uptake was similar to the estimate for the same period in the previous year (33% [95% CI: 31–35%]). For respondents aged 65 years and over (one of the identified high-risk groups), the estimated vaccination rate was 72% (95% CI: 69–76%), which is similar to previous years.

Table 7.  Proportion of Aboriginal and non-Aboriginal children fully immunised in NSW, for three age groups, December 2011 and December 2012

Table 8.  Proportion of eligible students in Years 7 and 10 who received human papillomavirus (HPV), hepatitis B (HepB), diphtheria-tetanus-pertussis (dTpa) and varicella (Vz) vaccine at school, NSW, 2011 and 2012

In 2012 Health Protection NSW:

• initiated a range of control measures to contain the measles outbreak, including sending letters to health care providers, issuing media alerts, developing measles alert posters and other materials for health care facilities and local GPs, and holding free local vaccination clinics in areas with high rates of measles infections

• continued an influenza prevention campaign that focused on three key respiratory disease prevention messages: Cover your face when you cough or sneeze; Wash your hands; and Stay at home if you're sick so you don't infect others. The campaign included distribution of The Spread of Flu is Up to You campaign posters; vaccination and pregnancy brochures; and infection control signage to health care facilities, aged-care facilities and a range of other sectors

• with local Public Health Units and an expert sub-committee of the NSW Tuberculosis Advisory Committee, continued to develop and implement strategies to eliminate transmission of tuberculosis in Aboriginal communities in NSW. This work involves better understanding barriers to early presentation to health services and non-compliance with treatment for latent tuberculosis infection, and investigation of strategies to raise awareness and increase early diagnosis of tuberculosis. The Northern NSW and Mid North Coast Local Health Districts have employed two Aboriginal Community Engagement Consultants to work directly with local Aboriginal communities on awareness-raising and prevention activities

• continued the NSW Arbovirus Surveillance Program, which included testing for both alphaviruses (Barmah Forest, Ross River and Sindbis virus) and flaviviruses (Alfuy, Edge Hill, Kokobera and Stratford) in mosquitoes trapped at 20 coastal, inland and metropolitan locations, and testing of chickens for antibody seroconversion to Murray Valley encephalitis virus and Kunjin virus at 10 sites in inland NSW from November 2011 to April 2012. During the 2011–2012 season inland areas had seen considerable arboviral activity with 67 isolates from mosquitoes and 15 seroconversions for Murray Valley encephalitis virus in chickens. Inland areas have also seen extremely high numbers of mosquitoes due to excessive precipitation and flooding. Coastal and Sydney metropolitan areas had low vector abundance and minimal arboviral activity

• issued statewide media releases in January, March and December, warning about the increased risk of mosquitoborne infections and how to prevent them. In addition, advice on mosquito control in flood-affected areas was provided to councils and the general public in March. These were supplemented by the information on the Ministry of Health website, development of guiding principles for environmental health officers, distribution of Fight the Bite posters and brochures, radio advertising and a range of local media messaging by public health officials.

In 2012 Health Protection NSW:

• together with local Public Health Units, helped more than 30 local water utilities develop risk-based drinking water management systems, consisting of documents, procedures and other supporting information for the safe supply of drinking water. These systems allow water utilities to document current practices that fulfil Australian Drinking Water Guidelines⁴ requirements, identify any gaps, conduct risk assessment workshops, identify critical control points (e.g. filtration and disinfection), and develop operational procedures for critical control points

• developed guidelines jointly with the NSW Office of Water (NSW Guidelines for Drinking Water Management Systems)⁵ and the NSW Food Authority (NSW Guidelines for Water Carters)⁶ to assist water suppliers to comply with the requirements of the NSW Public Health Act 2010 for all suppliers of drinking water to develop, by 1 September 2014, a management system based on the Framework for Management of Drinking Water Quality (Australian Drinking Water Guidelines 2011)⁷

• rebuilt the NSW Drinking Water Database, which holds the results of drinking water monitoring across regional NSW, to improve data management and reporting

• reviewed multiple applications for water recycling

• continued to regulate major water utilities (Hunter Water Corporation, Sydney Water Corporation and Sydney Catchment Authority), monitor compliance of utilities with the NSW Fluoridation of Public Water Supplies Act 1957, and oversee more than 100 regional water utilities.

In 2012:

• Housing for Health^8,9 projects were underway in Broken Hill, Tibooburra, Purfleet/Taree, Box Ridge/Coraki, Walhallow, Cabbage Tree Island and Toomelah/Boggabilla. NSW Health, in partnership with other state and Commonwealth agencies, has been delivering Housing for Health projects in the Aboriginal community housing sector across NSW since 1998. Housing for Health aims to test and repair or replace health hardware (mainly plumbing or electrical items) so that houses are safe and occupants have the ability to carry out evidence-based healthy living practices (such as washing people and clothes). The Program has surveyed and serviced over 2826 houses in 86 Aboriginal communities over the period 1998–2012. Over 81 000 items relating specifically to improved health and safety have been fixed, benefiting approximately 12 100 people

• integrated projects (i.e. Housing for Health projects run together with the Aboriginal Housing Office housing upgrade projects) were underway in Toomelah/Boggabilla, and preparations began for a project in Murrin Bridge.

In 2012:

• seven new Aboriginal communities began receiving improved water and sewerage services (bringing the total to 41 communities, and over 4000 people receiving improved water and sewerage services under the Program). Regional Public Health Units worked with communities, the NSW Office of Water, local water utilities and service providers to implement Risk-Based Water and Sewerage Management Plans. The Aboriginal Communities Water and Sewerage Program¹⁰ is a joint partnership between the NSW Government and the NSW Aboriginal Land Council. It aims to ensure adequate operation, maintenance and monitoring of water supplies and sewerage systems in over 60 Aboriginal communities in NSW. NSW Health is involved in the development and roll-out of the Program across the state.

In 2012 there were:

• 11 Aboriginal environmental health officer trainees participating in the Program

• 12 graduate Aboriginal environmental health officers from the Program

• nine Training Program partnerships under 50/50 funding agreements:

• 1. four partnerships with Public Health Units

  2. four three-way partnerships with Public Health Units and Local Government

  3. one partnership with Local Government.

In November 2012, when a period of unseasonably hot weather coincided with a number of major events in Sydney, the NSW Heatwave Sub Plan was activated for the first time. NSW Health worked closely with the NSW Police Force and other agencies to ensure the public were provided with clear and consistent advice on how to minimise the risk of heat-related illness.

In 2012 Health Protection NSW:

• developed supporting resources including forms, information sheets, fact sheets and audit tools to assist in the implementation of the Public Health Act 2010 and the Public Health Regulation 2012, both of which commenced on 1 September 2012

• held forums at 11 localities across the state to brief Local Government environmental health officers on the regulatory changes, and their implementation and enforcement methodology. Specific case studies were developed through a steering committee for presentation and study at the forums. Local Government feedback was positive, providing advice for improvements.

In 2012 Health Protection NSW:

• participated in the Heads of Asbestos Coordination Authority, a state-based interagency group that has been developing programs including a statewide plan for asbestos, a model asbestos policy for local councils, and a comprehensive public awareness campaign. Through this membership it also provides input into the newly formed Commonwealth Asbestos Safety and Eradication Agency.

In 2012 Health Protection NSW:

• supported two environmental studies in the Hunter Valley to help define the types of exposure of the community to particulate air pollution and determine the distribution and relative contribution of various sources to this pollution. This information will inform programs to reduce community exposure

• supported the Chief Health Officer’s Air Pollution Expert Advisory Committee, which provides independent advice on the scientific basis for management of the health effects of air pollution.

Communicable diseases and the environment pose many potential threats to human health. These potential threats are dealt with through a combination of four goals:

• preventing production of the threat (through, for example, immunisation, regulation of drinking water and working with planning agencies to ensure planning approvals address potential health threats)

• early identification of the threat (through surveillance systems such as the disease and exposure notification, and arbovirus surveillance systems)

• reducing the level of the threat (through strategies such as outbreak control, immunisation, and identification and treatment of the causes of diseases)

• effective communication (with the community, with appropriate health professionals, with other government agencies such as the NSW Environment Protection Authority and NSW Department of Planning, and with other jurisdictions, to respond to threats and reduce exposures).

Effective health protection for the NSW population is dependent on our success in achieving these four goals. That success is dependent on the skills, experience and advocacy of health protection workers across the state in identifying, responding to and communicating health threats to the NSW population.

Increasing international travel also increases the risk of importing enteric diseases such as hepatitis A, typhoid and paratyphoid, and other vaccine-preventable diseases such as measles and diphtheria. This underlines the need to maintain high vaccination coverage rates for all NSW children, and for all people planning travel, to ensure they have received all their routine vaccines, as well as specific travel vaccines such as hepatitis A and typhoid for some destinations.

Steady migration to Australia of people from countries with a high burden of tuberculosis necessitates maintenance of specialised tuberculosis services accessible across NSW for early detection, expert treatment and screening activities.